AMA Journal of Ethics®

April 2018, Volume 20, Number 4: 379-383

MEDICINE AND SOCIETY

Can Plastic Surgeons Maintain Professionalism within Social Media?
Pablo L. Gutierrez and Debra J. Johnson, MD

Abstract
Plastic surgeons have evolved their methods of reaching potential
patients by using various forms of social media. Such platforms can
educate, inform, and, for some, entertain. Social media now allows
consumers to compare themselves to a much wider, if not global, set of
peers that might further exacerbate their anxiety regarding their
appearance. Plastic surgeons should ensure that use of patient images
does not violate privacy or create unreasonable expectations about the
results that can be obtained; nor should plastic surgeons’ marketing
objectify women. Professionalism on the part of plastic surgeons, along
with the utmost respect for patients, must remain paramount.

Introduction
The internet has been a boon to the marketing of plastic surgery, as surgeons, patients,
and entrepreneurs have developed ways to satisfy the public’s desire for hearing real
patients’ stories, seeing before-and-after photos, and having a front-row seat in the
operating room to observe the performance of various procedures. Surgeons post videos
of surgical procedures on their personal websites, as well as on YouTube and Snapchat.
Some surgeons tout the educational aspect of such videos and their ability to allay
patient fears regarding surgery [1]. Many patients have written about their cosmetic
surgical experience, posting on blogs or posting testimonials on their surgeon’s website.
Web entrepreneurs have cashed in on this hunger by creating sites like RealSelf,
Healthgrades, and Vitals®, which enable patients to rate surgeons and procedures as well
as providing a forum where patients can query surgeons. Plastic surgeons who were
early adopters of the internet and social media found their practices flourishing, as the
celebrity associated with being an online sensation translated into instant credibility and
long lines of prospective patients [2-4]. Some physicians have even gone so far as to
“franchise” their online personas to earn money, helping other surgeons achieve similar
success [5]. Online marketing raises a number of ethical issues, some of which have
been addressed in professional guidelines.

Ethical Issues in Online Marketing of Plastic Surgery

The American Society of Plastic Surgeons (ASPS) lays as its cornerstone the promotion of
the highest standard of personal and professional conduct among its member surgeons.

AMA Journal of Ethics, April 2018 379

The ASPS Code of Ethics demands that no communication with the public be false,
fraudulent, misleading, or deceptive [6]. ASPS members are to render services with the
“full respect for human dignity” and to give each patient the “full measure of service and
devotion” [7]. In all public communications, which include all print or online marketing,
members “shall strive to use accurate and respectful language and images” [8].
However, the authority of a professional society’s code of ethics is limited by
governmental regulations regarding restraint of trade [9]. Because ASPS must rely on its
members’ personal professionalism for the maintenance of respectful standards for
advertising, professionalism and ethics have become a key part of the core curriculum of
plastic surgical residency training [10].

Unfortunately, some posted videos have raised ethical concerns because they feature
surgeons dancing and singing in the operating room, telling jokes to a camera instead of
focusing on the patient, or cradling removed body parts in their arms like a baby [11-13].
Members of ASPS have been justifiably outraged when viewing such videos. Complaints
have been lodged with the ASPS Ethics Committee for investigation. In fact, the ASPS
Code of Ethics demands that members “expose, without hesitation, illegal or unethical
conduct of fellow Members of the profession” [7]. The ASPS Ethics Committee carefully
evaluates any complaints. Those members found to be in violation are referred to the
Judicial Council for adjudication. The member might simply be asked to make a correction
or to withdraw the offending advertisement. In severe cases, a violation might result in a
member being asked to resign or being expelled from the society [6]. The second author
(DJJ), who has served in leadership positions in ASPS, is aware of several such cases. To
take one example, the ASPS Code of Ethics prevents plastic surgeons from offering
surgery as a contest prize or even as a donation to a charity auction. When the reality
television program The Swan aired in 2004, it featured a competition wherein “ugly
duckling” personal stories were compared. The contestant with the most compelling
story was awarded free plastic surgery. The surgeon involved is no longer a member of
ASPS. As another example, a Snapchat posting of an ASPS member surgeon singing a
rap song was deemed a violation not because it included expletives but because the
ASPS member surgeon claimed superiority over other plastic surgeons, which is also a
violation of the ASPS Code of Ethics. In this case, the surgeon was required to remove
the posting.

Attempting to judge the ethicality of videos in which plastic surgeons show consenting
patients and their procedures is much more subjective. The patient might be relatively
nude, sometimes with strategically placed emojis covering nipples or genitalia. As such,
these graphic videos can serve as unintended entertainment. The second author (DJJ)
became aware of one surgeon’s Snapchat postings when a preteen related that she and
her friends excitedly gathered daily to watch his videos of naked women undergoing
surgery. While some might be offended by such nudity and the often lighthearted banter
between patient and physician that accompanies it, patients have given written consent

380 www.amajournalofethics.org
to have their body filmed and the images posted to the internet. Michael Salzhauer says
patients particularly seek his services in the hope that their surgery will be posted on
Snapchat or featured on his television program [4].

Guidelines for the Use of Patient Images on Social Media

The ASPS Code of Ethics contains general guidelines for the use of patient images.
Patient images placed in a journal article, textbook, an educational PowerPoint
presentation, or online require the patient’s consent [6]. Patients have every right to
refuse this use of their personal images. There can be no coercion on the part of a plastic
surgeon to get a patient to participate in online marketing. Patients should, however, be
informed that once an image is posted online, it might be permanently discoverable.
Clark Schierle’s group at Northwestern recently published video recommendations,
which basically reiterate the Code’s requirements [11]. They also suggest the use of an
independent videographer so that the surgical team’s attention is focused on the task at
hand and not distracted by the filming of the video [11].

Patients who decide they no longer want their images used for educational or marketing
purposes might find it is difficult to remove undesired images from the internet [14].
Depending on where an image is posted, ownership of the image can default to the
business entity that owns the website [15]. Thus, both the patient and the physician can
lose control over the images.

When filming a surgical video, the surgeon should put the patient’s safety and welfare
first and foremost. Procedural videos, while educational, should never pull the surgeon’s
attention away from the patient. Patient video images must be respectful and
appropriate. Identifying marks or tattoos should be covered or eliminated, body parts not
essential for understanding the procedure shown should not be in view, and all metadata
attached to images must be scrubbed to prevent patient identification [16]. Ideally,
plastic surgeon websites should demonstrate real people with real outcomes, so that
prospective patients can understand the variability and reality of achievable results [6].
When models are used, they must be identified as such, and it must be clarified that “the
model has not received the advertised services” [17].

Finally, there are ethical considerations regarding which patients are appropriate
candidates for surgery. While some would never consider surgically altering their bodies,
for many people, the correction of perceived faults is acceptable. It has been
demonstrated that cosmetic surgery can improve self-esteem and confidence [18, 19].
Plastic surgeons are tasked with determining when patients have a “healthy” concern
regarding their appearance and must strive to avoid treating patients with body
dysmorphic disorder or those whose concerns far outweigh their perceived deformity
[20-22].

AMA Journal of Ethics, April 2018 381

Conclusion
The internet and social media have increased the penetration of cosmetic surgery into
the public’s consciousness. Plastic surgeons are keenly interested in performing desired
surgery and being remunerated for doing so, but they must strive to advertise in a
professional and ethical manner. To maintain the respect of medical peers and the public,
it will be critical for plastic surgeons to use social media to provide factual information
regarding cosmetic surgery while protecting patient identity and professionally caring for
the patient population. The ASPS, through its Social Media Subcommittee, monitors this
ever-evolving landscape and will continue to provide education and guidance to its
members and the public.

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Pablo L. Gutierrez is a writer, musician, and medical school applicant.

Debra J. Johnson, MD, is the immediate past president of the American Society of Plastic
Surgeons, on the board of directors of the American Society of Plastic Surgeons, and a
clinical professor of plastic surgery at the University of California, Davis School of
Medicine.

Related in the AMA Journal of Ethics

Advertising Cosmetic Surgery, April 2018
Plastic Surgery’s Contributions to Surgical Ethics, April 2018
When Is Advertising a Plastic Surgeon’s Individual “Brand” Unethical?, April 2018
When Is Posting about Patients on Social Media Unethical “Medutainment”?, April 2018

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect
the views and policies of the AMA.

Copyright 2018 American Medical Association. All rights reserved.

ISSN 2376-6980

AMA Journal of Ethics, April 2018 383